4/3/2016 Stuttering in preschoolers: Multifactorial perspective on - PDF document

4/3/2016 Stuttering in preschoolers: Multifactorial perspective on its nature, assessment and treatment Victoria Tumanova, Ph.D., CF-SLP Assistant professor, Department of Communication Sciences and Disorders, Syracuse University vtumanov@syr.edu Iowa Conference on Communication Disorders April 8, 2016 Overview of the talk • 1 st hour • Nature of developmental stuttering • Normal disfluency and onset of stuttering in preschoolers • Spontaneous recovery and its predictors • 2 nd hour • Constitutional, developmental, environmental and learning factors in stuttering development • 3 rd hour • Assessment of stuttering following the multifactorial perspective • 4 th hour • Treatment approaches for preschool-age children What is stuttering? • It is an observable behavior (E) • Disfluency and Stuttering reflect a disruption in the smooth transitioning between sounds, syllables , and words. • It is a disorder of communication 1

4/3/2016 Wha hat are STU TUTT TTERING be behaviors? • BETWEEN-WORD disfluencies • Interjections • Revisions • Phrase repetitions • WITHIN-WORD disfluencies Wi Within-word dis isfluencies (1) Sound/syllable repetitions (2) Single-syllable whole word repetitions (3) Disrhythmic phonation sound prolongations broken words blocks (silent prolongations) STUTTERING IS A FORM OF SPEECH DISFLUENCY CHARACTERIZED BY A RELATIVELY HIGH PROPORTION OF WITHIN-WORD SPEECH DISFLUENCIES AND ASSOCIATED BEHAVIORS 2

4/3/2016 Core beh ehaviors of stut tuttering • Basic speech behaviors (=within-word disfluencies) • Repetitions • Prolongations • Silent blocks • They are involuntary • They are out of the PWS’s control • Loss of control • Helplessness • Characterizes stuttering as opposed to normally disfluent speech Sec econdary Beh ehaviors • Reactions to core behaviors • Attempt to end or avoid stuttering • Are learned patterns • Escape and avoidance Nor ormal Di Disfluency and and th the e De Development of of Stut Stuttering 3

4/3/2016 ONS NSET OF STUTTERIN ING: : THE FAC ACTS • Onset of stuttering typically between 2-4 years of age • Probability of stuttering onset decreases with age • Lifetime incidence (in USA and Western Europe) approximately 4-5% of the population • Incidence is an index of how many people have stuttered at some time in their lives • Prevalence ranges from 0.5% to 1% • Prevalence indicates how wide-spread the disorder is (how many people currently stutter) • Higher prevalence in preschool-age children • Lower prevalence in older children and adults Yai airi and nd Ambr brose 200 005 • “Early childhood stuttering” book • Gathered longitudinal data on 146 CWS and 59 CWNS • Onset • Sudden 40% • Intermediate (over 1-2 weeks) 30% • Gradual (3 or more weeks) 27% • First disfluencies • Only 35% of parents described their child’s disfluencies as easy repetitions • More iterations per instance of repetition • Rapid rate of iterations • Disfluency clusters Joh ohns nson on et al., 1959. The he Onse set of Stutterin ing Disflu fluenc ncy types s (at onse nset) ) of child ildren n thou ought to be normally lly disflu fluent versus sus chil ildr dren n thou ought to be st stutterin ing 4

4/3/2016 Tum umanova et t al. l. 201 014 stud udy • Parental concern and frequency of disfluency for preschool-age children • When do parents become concerned about their child’s fluency? • 399 children 3-5:11 y/o and their parents participated • Overall frequency of disfluencies in CWS and CWNS • How disfluent are preschool-age children? • 472 children 3-5:11 y/o participated Tumanova, V., Conture, E. G., Lambert, E. W., & Walden, T. A. (2014). Speech disfluencies of preschool-age children who do and do not stutter. Journal of communication disorders , 49 , 25-41. Par arental Conc ncern abo bout Stut tuttering • 399 children 3-5:11 y/o participated • Parents of 221 children were concerned • 164 boys, 57 girls, mean age = 49 months • average of 8.53% stuttered disfluencies • average of 3.51% normal/other disfluencies • Parents of 178 children were NOT concerned • 93 boys, 85 girls, mean age = 50 months • average of 1.44% stuttered disfluencies • average of 2.87% normal/other disfluencies Tumanova, V., Conture, E. G., Lambert, E. W., & Walden, T. A. (2014). Speech disfluencies of preschool-age children who do and do not stutter. Journal of communication disorders , 49 , 25-41. Stut utter ered d Di Disfluencies es pe per r 100 100 wor ords 5

4/3/2016 Nor Normal/Ot Other er Di Disfluen encies pe per r 100 100 wor ords Crit iteria for Stu tuttering Diag iagnosis • We begin to suspect that a child is either stuttering or at risk for developing a stuttering problem if (s)he meets BOTH of the following criteria • Produces THREE or more WITHIN-WORD speech disfluencies per 100 words of conversational speech (i.e., sound/syllable repetitions and/or sound prolongations) • Parents and/or other people in the child’s environment express concern that the child stutters. St Stut utterin ing as as a a di disorder: : Eti tiology (i (impli licatio ions for or tr trea eatment) ) • So FAR… • Stuttering as a behavior 6

4/3/2016 Over ervie iew Nature interacting with nurture (from Conture, 2001): If a disorder thought to be the result of a combination of genetic and environ mental influences, its etiology can be referred to as multifactorial Example of an Interaction between environment (salt) and person (finger) making a weakness or difficulty more pronounced Consti titutio ional Fac actors: Gen enes • Stuttering often runs in families • 30 to 60% of PWS have family histories of stuttering • Research is underway to identify genes associated with stuttering • Single gene for transient stuttering; two or more genes for chronic stuttering • Twin studies, adoption studies provide evidence that environmental factors are also important • Twin studies show that whether stuttering occurs is 2/3 genetics and 1/3 environment 7

4/3/2016 Cli linical Impl plications • Parents should be told that stuttering is often inherited, not a result of bad parenting • SLPs can’t change a child’s genes but they can help modify this child’s environment Con onsti tituti tional Fac actors: : Brai ain St Structu ture and nd Fun unction on • PWS have less dense white matter tracts in the area of left operculum (tracts that are thought to connect sensory, planning and motor areas of the brain) (Sommer et al., 2002) • White matter neuroanatomical differences have been reported in CWS as well (Chang et al., 2015) • Brain areas used for sensory integration are not efficiently connected to motor planning and motor execution areas www.humanconnectomeproject.org Con onsti tituti tional Fac actors: : Brai ain St Structu ture and nd Fun unction on • Meta-analysis by Brown et al., 2005 • Overactivation in right hemisphere areas that are homologous to left hemisphere areas active for speech production • Overactivation in left hemisphere areas related to motor control of speech • Deactivation of left auditory cortex during stuttering 8

4/3/2016 Sen ensory and nd Sen ensory-Motor Fac actors • PWS are slower in initiating a movement • PWS are more variable • Slower reaction times • Slower on nonspeech sequencing • Slower at tapping at a comfortable rate, but faster and more variable at a fast rate • PWS show lower accuracy when performing auditory tasks • Poorer at auditory-motor tracking • Weaker-than-normal vocal adjustments to perturbations during sustained vocalization (Loucks, Chon & Han, 2012) • Masking and other changes in auditory feedback decrease stuttering Clin linic ical Imp mpli licatio ions • Evidence that treatment changes neurological function • May suggest that treatments restore effective sensory- motor control of speech • Because PWS process more slowly, slower speech may facilitate fluency • Because of sensory processing deficits, masking, DAF, attention to kinesthetic feedback may be helpful in treatment Constitutional al Factors: : Emot otio ion and nd Tem emperam ament • Emotion may increase stuttering, and stuttering may increase emotion • Important findings • PWS are not more anxious than PWNS, but more anxiety produces more stuttering • Autonomic arousal associated with stuttering • PWS may have more inhibited temperaments; may be more emotionally conditionable • Emotional processes: • CWS less adaptable to novelty than CWNS • CWS more emotionally reactive, less emotionally and attentionally regulated • Emotions interacting with speech-language planning and production: • CWS as apt to stutter during/after positive as negative arousal 9